[Clinical characteristics and surgical effect observation of congenital aniridia combined with cataract]

Objective: To analyze the clinical manifestations, surgical approaches and postoperative prognosis for the cases of congenital aniridia combined with cataract. Methods: In this retrospective case series, 26 patients diagnosed with congenital aniridia combined with cataract were collected from Zhongshan Ophthalmic Center from February 2002 to August 2016. The Clinical data were collected to analyze the clinical features, surgical approaches and postoperative prognosis. T-test was used for statistical analysis. Results: Twenty-six bilateral congenital aniridia patients were included in the case series, with 50% male cases. The average age for the first visit was (8.72±8.06) years old. Hereditary patients constitutes 30.8% (8/26) of the total number. The proportions for bilateral and unilateral cataracts were 88.5% (23/26) and 11.5% (3/26) respectively, and 49 eyes suffering from both congenital aniridia and cataract were therefore included in the final analysis. The most common morphology cataract subtypes were lamellar cataract (24.5%, 12/49), posterior subcapsular cataract (22.4%, 11/49), and total cataract (18.4%,9/49). The observed ocular comorbidities included nystagmus (36.7%, 18/49), vitreous opacity (28.6%, 14/49), foveal hypoplasia (20.4%, 10/49), ametropia (12.2%, 6/49), exotropia (12.2%, 6/49), congenital glaucoma (12.2%, 6/49), esotropia (4.1%, 2/49), congenital ptosis (4.1%, 2/49), lens ectopia (4.1%, 2/49), scleral staphyloma (2.0%, 1/49) and pigmentary degeneration of retina (2.0%, 1/49). 30.6% (15/49) eyes were performed the cataract extraction surgery. The percentage of postoperative best corrected visual acuity (BCVA) for ≥0.1 and ≥0.3 were 93.3% (14/15) and 20.0% (3/15) respectively. Evaluated ocular pressure (33.3%, 5/15), severe posterior capsular opacification (PCO) (13.3%, 2/15) and choroidal hemorrhage combined with choroidal detachment (6.7%, 1/15) were detected as the postoperative complications. Followed by cataract extraction, 80.0% (12/15) eyes were sequentially performed the intraocular lens implantation, while, 20.0% (3/12) eyes remained aphakia due to ocular comorbidities. Conclusions: Congenital aniridia combined with cataract are rare diseases, calling for the precious retrospective researches. This disorder tended to affect both eyes and occurred hereditary. The clinical courses of the cases presented progressive features. Ocular comorbidities were the crucial factors to influence the surgical approaches and postoperative prognosis. (Chin J Ophthalmol, 2017, 53: 821-827).

Risk factors for extra-pulmonary tuberculosis compared to pulmonary tuberculosis

BACKGROUND

Tuberculosis (TB) continues to be a major global health problem. Extra-pulmonary TB (EPTB) manifests with protean symptoms, and establishing a diagnosis is more difficult than pulmonary TB (PTB).

SETTING

A university-affiliated hospital in southern Taiwan.

OBJECTIVE

To analyse the risk factors for EPTB compared with PTB.

DESIGN

This retrospective study compared patients with EPTB and PTB in southern Taiwan by analysing their demographic data and clinical underlying diseases. Risk factors for EPTB were further analysed.

RESULTS

A total of 766 TB patients were enrolled in this study, with 102 (13.3%) EPTB and 664 (86.7%) PTB cases. Of the 766 patients, 3% of PTB patients had EPTB, while 19.6% of EPTB patients also had PTB. The most frequently involved EPTB site was the bone and joints (24.5%). The incidence of EPTB vs. PTB decreased significantly for each decade increase in patient age. Multivariate logistic regression analysis showed that being female, not being diabetic, having end-stage renal disease and not smoking were independent risk factors for EPTB.

CONCLUSION

This study defines the risk factors for EPTB compared with PTB. Awareness of these factors is essential for physicians to have a high index of suspicion for accurate and timely diagnosis.

Use of parenteral testosterone prior to hypospadias surgery

Surgical correction of genital defects was formerly proposed when the size of the penis was sufficient to permit easy surgical repair. To enlarge penile size, temporary stimulation with testosterone or dihydrotestosterone cream has been used; however, the results were not only inconsistent, but absorption was also variable. We report our experience with parenteral testosterone as an adjunct to reconstructive genital surgery in 25 patients aged 6-18 months from July 1999 to December 2000, including 8 with penile hypospadias, 15 with penoscrotal hypospadias, and 2 with perineal hypospadias. Each had a penis that was significantly smaller than usual. Testosterone enanthate 25 mg was given i.m. once per month for a total of three doses before surgical repair. Penile length and glans circumference were measured before therapy and at operation. Side effects such as the development of pubic hair and acne were monitored. Bone age was checked 1 year later. An increase in penile length (from 19.8 +/- 2.4 mm to 23.8 +/- 2.0 mm) and glans circumference (from 27.4 +/- 1.4 mm to 37.84 +/- 2.6 mm) was apparent in all except 2 patients (P < 0.001 for both, paired t-test). Four patients had a significant increase in either penile length or glans circumference after the initial dose so that no further injections were required. No definite secondary effects were found. Preoperative parenteral testosterone therapy thus causes a significant increase in penile length and glans circumference without apparent side effects. We suggest that this therapy prior to microphallic hypospadias repair is appropriate.

Hepatic Schistosomiasis japonica in a patient with gallstones and bile duct stones--a case report

Schistosomiasis, a common parasitic disease in many countries, is found as imported cases in Taiwan. Responsible for human infections are five species, one of which, Schistosoma japonicum, is currently endemic in China and South-east Asia. Chronic infection with S. japonicum may lead to the development of liver fibrosis, calcification and portal hypertension. Under investigation by sonography and computed tomography (CT) scan, a peculiar "turtle-back" appearance of liver fibrosis and calcification may be found. Herein, we report a case referred to our department due to jaundice. The sonography of liver showed typical "turtle-back" appearance. Gallstones and bile duct stones were also found in this case. Surgical interventions with percutaneous transhepatic biliary drainage (PTBD), cholecystectomy and choledocholithotomy were performed to relieve the obstructive jaundice and remove the stones. There were no parasitic eggs in the extracted stones or in drained bile juice. However, deposits of calcified S. japonicum eggs in liver parenchyma and portal tracts were identified in liver biopsy. No special treatment was given for the schistosomiasis japonica because the calcified parasitic eggs were the sequelae of past infection.

Effect of N(G)-nitro-L-arginine methyl ester on intestinal permeability following intestinal ischemia-reperfusion injury in a rat model

Subclinical intestinal ischemia-reperfusion injury (IRI) causes an increase in mucosal permeability and may represent an early event in the pathogenesis of necrotizing enterocolitis in premature infants. Previous studies suggested that continuous, endogenous formation of nitric oxide (NO) maintains the mucosal integrity of the intestine, thus protecting the gut from injuries from blood-borne toxins and tissue-destructive mediators. This study was undertaken to assess whether the inhibition of NO production causes an increase in intestinal permeability in rats following IRI. Sprague-Dawley rats weighing 200-300 g were divided into 4 groups: (1) untreated group (normal control); (2) ischemia-reperfusion group; (3) early N(G)-nitro-L-arginine methyl ester (L-NAME), a specific inhibitor of NO production, treatment group, and (4) late L-NAME treatment group. Transient IRI was induced by 30-min occlusion, followed by reperfusion of the isolated ileal loop. The L-NAME was administered 15 min before and after mesenteric ischemia as a 25-mg/kg bolus. Fluorescein isothiocyanate-dextran (FITC-D) was used to quantitatively assess the alteration in mucosal permeability of the intestine. There was no significant increase in the portal vein FITC-D level among normal controls, ischemia-reperfusion group and late L-NAME-treated group, but there was an approximately 6-fold increase in the early L-NAME treatment group. The pathological features of the intestine following IRI include denudation of the villus epithelium and reduction of villus height, associated with marked inflammatory cell infiltration over the lamina propria. These results suggest that endogenous NO may play a role in the protecting intestinal integrity after IRI.

99mTc-sulphur-colloid and heat-denatured 99mTc-labelled red cell scans demonstrating a giant intrapelvic spleen in a girl after splenectomy

A 17 x 12 x 5-cm giant intrapelvic mass in a 14-year-old girl is reported. This mass developed 6 years after a splenectomy for splenic torsion. The heat-denatured 99mTc-labelled red cell scan and 99mTc-sulphur-colloid scan confirmed the specific red cell sequestration function and reticuloendothelial activity in the giant intrapelvic spleen. The size and development of the giant intrapelvic spleen are unusual. The usefulness of functional images to diagnosis the nature of the intrapelvic mass is well demonstrated.

Biliary atresia at the dawn of a new century

Biliary atresia is a unique disorder in pediatric surgery. The incidence is 1 in 3,500 to 20,000 live births, but the disorder accounts for more than half of the patients requiring liver transplantation. After Kasai operation, the 5- and 10-year survival rate without the need of transplantation are 37-48% and 18-28%, respectively. An infectious pathogen, particularly the virus, has long been implicated as the causative agent of biliary atresia, but none has ever been identified. Ductal plate malformation is likely to be important in the pathogenesis of biliary atresia. Earlier diagnosis is associated with a better prognosis and biliary atresia should be considered in the differential diagnosis of prolonged jaundice in any infants older than 2 weeks of age. The experience of the surgeon and surgical decade are determinant in achieving success of the Kasai operation. Postoperative cholangitis affects more than 45% of the patients receiving Kasai operation and the afflicted patients are at risk of cessation of bile flow and exacerbation of preexisting liver cirrhosis. Hepatic fibrosis starts at the moment when biliary atresia develops and the ongoing inflammation will end up with liver cirrhosis and hepatic failure in most patients, including some with adequate bile drainage. The inhibition of liver cirrhosis in mice or rats by gene therapy, such as telomere gene delivery, transduction with the hepatocyte growth factor gene or blockade of TGF-beta signaling, may provide a new strategy to rejuvenate the ailing liver associated with biliary atresia in the future.

Overview of migraine

Migraine, one of the most common incapacitating headaches, afflicts 23 million adults in the United States. There is a controversy in the literature on the theoretical perspective of migraine, the efficacy of treatment strategies, measurement, and correlates. Thus, more research is needed on these issues. A wide range of treatments is available for migraine. In addition to terminating migraine headache, appropriate migraine care includes preventing its attacks and improving patients' quality of life by administrating pharmacologic preparations in conjunction with a variety of alternative methods.

Treatment and outcome of congenital diaphragmatic hernia

BACKGROUND AND PURPOSE

Congenital diaphragmatic hernia (CDH) is a challenging condition and is associated with a high mortality rate; optimal therapy remains unclear. This retrospective study describes the clinical characteristics of treatment and outcome in 48 infants with CDH.

METHODS

Twenty-eight male (58%) and 20 female (42%) infants with CDH were treated from 1987 through 1998. The goals of the ventilator strategy were permissive hypercapnea (PaCO2 < or = 55 mm Hg) and avoidance of hyperventilation. Infants were initially ventilated with an intermittent mandatory rate of 40 to 60 per minute, peak inspiratory pressure of 20 to 25 cm H2O, and positive end-expiratory pressure of 5 cm H2O. High-frequency positive pressure ventilation was used if hypoxemia or severe hypercapnea (PaCO2 > 60 mm Hg) occurred. Most infants underwent repair after 3 days of age and only four infants underwent early repair within 24 hours of birth. A prophylactic chest tube was placed in the ipsilateral hemithorax postoperatively in all patients treated before 1996. The severity of respiratory distress was estimated by alveolar-arterial oxygen difference, oxygenation index, and alveolar-arterial ratio.

RESULTS

Forty-six patients presented with Bochdalek CDH, and two with Morgangni CDH. Antenatal diagnosis was made in 10 cases. Respiratory distress was the major manifestation and usually occurred immediately after birth. Six cases were diagnosed several months after birth and presented mainly with gastrointestinal symptoms. Eleven patients died before surgery and 37 patients underwent surgical repair. Two infants died postoperatively because of congestive heart failure and tension pneumothorax, respectively. The overall mortality rate was 27%. The major causes of mortality were severe respiratory failure, persistent pulmonary hypertension, pneumothorax, and associated anomalies.

CONCLUSION

Nearly 75% of patients in this series survived. This suggests that noninvasive respiratory care combined with delayed surgery may be an acceptable strategy for the treatment of CDH, and can be used in most medical institutions without equipment for extracorporeal membrane oxygenation therapy.

Sonographic features related to volvulus in neonatal intestinal malrotation

This 3 year prospective study evaluated the sensitivity and specificity of abdominal ultrasonography and color Doppler ultrasonography in 31 neonates with suspected malrotation or malrotation with volvulus. Water instillation was used to detect duodenal dilatation, edema, and malrotated bowels. Twenty patients with ultrasonographic characteristics of inversion of the superior mesenteric artery and superior mesenteric vein were later surgically proved to have malrotation. Nine of these 20 patients also had volvulus. Sonographic features suggestive of volvulus included duodenal dilation with tapering configuration (8 of 9 cases, 89%), fixed midline bowel (8 of 9 cases, 89%), whirlpool sign (8 of 9 cases, 89%), and dilation of the distal superior mesenteric vein (5 of 5 cases, 100%). The sensitivity and specificity of duodenal dilation with tapering configuration for detecting volvulus were 89% and 92%, respectively; of fixed midline bowel, 89% and 92%; of whirlpool sign, 89% and 92%; and of dilation of distal superior mesenteric vein, 56% and 73%. The results of this study indicate that ultrasonographic features of inversion of the superior mesenteric artery and superior mesenteric vein could aid in the diagnosis of malrotation, and certain sonographic features can also be used to evaluate volvulus, a condition requiring emergent operation.

Aminoguanidine attenuates hemodynamic and microcirculatory derangement in rat intestinal ischemia and reperfusion

BACKGROUND

Nitric oxide (NO) participates in the regulation of hemodynamic and microcirculatory changes in intestinal ischemia and reperfusion (I/R). However, the nature of the involvement of an inducible NO release has been controversial. This study evaluates the impact of an inducible NO synthase inhibitor, aminoguanidine, used as a treatment in a rat intestinal I/R model.

METHODS

We investigated the hemodynamics by measuring the mean arterial pressure (MAP), and the microcirculatory responses of the intestine and liver to systemically administered aminoguanidine by use of laser-Doppler flowmetry (LDF), in vivo microscopy, and flow cytometry.

RESULTS

During the 30-min ischemia of the selected 20-cm ileal segment, no MAP change was noted. At reperfusion, a marked decrease of MAP was noted and the lowest levels were noted 3 hours after reperfusion (67 +/- 4% vs. 99 +/- 5% in sham-operated control animals). A marked decrease in liver perfusion as measured by LDF was noted 1 hour after reperfusion and remained low at 5 hours (72 +/- 4% vs. 97 +/- 3% in sham-operated control animals). A marked decrease in intestine perfusion was noted by using LDF 1 hour after reperfusion and remained low at 5 hours (43 +/- 3% vs. 92 +/- 4% in sham-operated control animals). The flow velocity of the postcapillary venules of the intestine was markedly decreased (1.01 +/- 0.62 vs. 2.67 +/- 0.34 mm/s in sham-operated control animals) at 5 hours after reperfusion. The flow velocity of the postsinusoidal venules of the liver was also markedly decreased (1.01 +/- 0.62% vs. 2.67 +/- 0.34% in sham-operated control animals). Leukocyte-endothelial interaction (adhesion) was increased in the postcapillary venules of the intestine (54 +/- 12 vs. 6 +/- 4/microm2 in sham-operated control animals) and in the postsinusoidal venules of the liver (32 +/- 8 vs. 2 +/- 2/microm2 in sham-operated control animals). Concomitantly, the granulocyte count was increased (9.1 +/- 0.6 vs. 2.1 +/- 0.3% of total circulating leukocytes in sham-operated control animals), with an increase of CD 11b expression. Aminoguanidine administration (1 mg/kg) 0.5 hour before ischemia and 1 hour after reperfusion significantly increased MAP, increased intestine and liver perfusion, decreased adhesion, and decreased circulating granulocytes and CD 11b expression.

CONCLUSION

Inhibition of an inducible NO release by aminoguanidine in intestinal I/R can attenuate hemodynamic and microcirculatory derangement.

Repair of hypospadias complications using the tubularized, incised plate urethroplasty

BACKGROUND/PURPOSE

Secondary procedures to correct complications after hypospadias repair remain challenging especially for "hypospadias cripples." The tubularized, incised plate urethroplasty was first introduced by Snodgrass for the repair of primary hypospadias in 1993. The authors used this procedure to correct the complications after hypospadias repair in patients who had no abundant local skin flaps to be used for a neourethra.

METHODS

Six patients underwent tubularized, incised plate urethroplasty for the correction of complications of hypospadias repair performed the previous year, including a large urethrocutaneous fistula (n = 1) and disruption of the neourethra (n = 5). Prior surgical procedures included transverse island tube urethroplasty in 4 cases and 2-stage urethroplasty in 2 cases. The average patient age at the time of secondary procedure was 4.6 years (range, 1 to 12 years).

RESULTS

The mean follow-up period was 6 months (range, 2 months to 1 year). All the patients obtained a functional neourethra with a vertical, slitlike meatus. A small fistula developed in one child and mild meatal retraction in another.

CONCLUSIONS

The tubularized, incised plate urethroplasty offers few complications and good cosmetic results. The authors recommend its use for patients who have had repeated surgeries for hypospadias repair, especially those in whom only limited local skin flaps can be utilized for a neourethra.

Prenatally detected tumor mass in the adrenal gland

BACKGROUND/PURPOSE

Screening programs using urinary vanillylmandelic acid have detected neuroblastomas in early infancy with some success. With the widespread use of ultrasonography in modern obstetric practice, use of ultrasonography to screen for fetal neuroblastoma seems to be reasonable and practical.

METHODS

Seven fetuses had suprarenal masses detected by maternal ultrasound scan at 32 to 37 weeks' gestation between 1993 and 1998. They were delivered normally if the pregnancy was uncomplicated, especially if it was without maternal preeclampsia or fetal hydrops. Each mass was further confirmed by ultrasound scan, computed tomography, or magnetic resonance imaging in the neonatal period. Tumor excision was performed at the age of 6 to 38 days of life.

RESULTS

The size of the masses measured ranged from 2.0x2.0 cm to 4.5x4.5 cm. The diagnosis was adrenal hemorrhage in 1 neonate, Evan's stage I neuroblastoma in 3, and stage IV-S neuroblastoma in 3. All of the specimens with a diagnosis of neuroblastoma showed a favorable histology by the Shimada classification system. Infants with stage I disease were treated with tumor excision only, and they had survived without disease by 14, 18, and 25 months of follow-up. One infant with stage IV-S neuroblastoma was treated further with minimal chemotherapy and has survived without disease at the 66-month follow-up examination. Another child with stage IV-S neuroblastoma has survived with local recurrence and increasing liver metastasis and was still on chemotherapy at the 2-month follow-up examination. The third child with stage IV-S disease presented with massive hepatomegaly and bone marrow involvement, and disseminated intravascular coagulopathy had developed. The patient died on the 5th day of life without surgical intervention.

CONCLUSIONS

The increasing use of obstetric ultrasonography has made the prenatal screening of neuroblastomas possible. The prognosis of infants with a suprarenal mass may be improved with this early detection and early surgical intervention.

Anorectal malformations--update 1998

Anorectal malformation is a common congenital anomaly. Its correction still challenges the wisdom and expertise of the pediatric surgeon. From 1977 through 1997, approximately 400 cases of this anomaly were treated at this institution. Prior to 1985, cut-back anoplasty and translocation anoplasty were the treatments of choice for the low anomalies, and abdominoperineal pull-through anoplasty or sacroperineal anoplasty (and their modifications) preferred for the intermediate or high defects. Since 1985, posterior sagittal anorectoplasty (PSARP) has been adopted exclusively as the operative procedure for the correction of the entire spectrum of anorectal malformations. Two hundred patients have undergone this procedure either primarily (N = 166) or secondarily (N = 34). PSARP is a procedure which enables the surgeon to repair the pelvic anatomy under direct vision, maximally utilizing all the existing continence muscles and hence resulting in better fecal continence. With minimal, limited or maximal division of the continence muscles under one same skin incision, the entire spectrum of this defect can be repaired. The result of cosmesis is generally regarded as better, and the immediate postoperative complications are fewer. In spite of all efforts, 10 to 30% of patients still suffer from total fecal incontinence which is intractable to all kinds of medications and enemas. A bowel management program with large volume enemas, either through the anus or a Malone appendicostomy, retrogradely or antegradely, to wash out stool in the colon and rectum may be necessary to keep the patient clean and more socially acceptable. Biofeedback therapy offers another alternative to improve continence with the development of better computer systems and manometry equipment. This review provides a new concept of the fecal continence mechanism and an operative procedure for constructing a new anorectum based on this concept for the treatment of patients with anorectal malformations.

Ultrasonographic study of the sternocleidomastoid muscle in the management of congenital muscular torticollis

BACKGROUND

Congenital muscular torticollis (CMT) in infancy is caused by the fibrotic change of the sternocleidomastoid muscle (SCMM). The etiology and management strategies remain controversial.

METHODS

One hundred ninety-seven infants and children aged 1 month to 16 years who had CMT were examined by real-time ultrasonography of the SCMM between June 1995 and September 1996 in a prospective and longitudinal study. A total of 362 examinations were performed. There were 122 boys and 75 girls.

RESULTS

The right side was involved in 117 patients (59.3%), the left side in 79 patients (40.1%), and both sides in one patient. The sonographic findings were homogeneous or heterogeneous (patchy) hyperechoic lesion within the SCMM, and all were diagnostic. The ultrasonographic appearance of the SCMM in this study has a close resemblance to the clinical course of CMT. The extent of fibrosis as represented by the cross section of lesion to muscle ratio (L/M ratio) decreased from 83.6% at 2 months to 59.9% at 9 months of age and further decreased to 40% beyond 1 year of age. This consistent decrease in fibrosis was caused by the increased normal muscle volume at the periphery and by the regenerated muscle fibers within the lesion. In this series of 197 patients, 32 (16.2%) eventually underwent surgery to release the SCMM because of persistent head tilt, chin deviation and limited range of neck motion beyond 1 year of age. The L/M ratio of the operative group was 62.7 +/- 16.0% compared with an L/M ratio of 54.5 +/- 14.2% (P = .035) for the nonoperative group at 1 year of age. The extent of fibrotic change in the cross section of the muscle was a significant factor in determining prognosis. In the longitudinal section, the fibrotic change was limited to only the lower third of the SCMM in 27 patients, and all of them recovered without operation. In 95 patients, the fibrotic lesion was limited to the middle and lower third or middle third only, and only six (6.3%) underwent operation. However, in 75 cases the entire length of muscle was involved, and 26 (34.7%) required surgical release of the contracted muscle. Whole-length muscle involvement was also important for predicting recovery without operative intervention.

CONCLUSIONS

Ultrasonographic study of the SCMM is not only a valuable diagnostic tool but can also serve as a useful guideline for the treatment of infants who have congenital muscular torticollis.

Factors related to detection of blood flow by color Doppler ultrasonography in intussusception

Color Doppler ultrasonography was performed in 125 patients with 134 intussusceptions. Color flow was present in 121 cases of intussusception (group A) and was absent in 13 cases (group B). Young age and duration of symptoms greater than 48 hr were significantly related to the nonvisualization of blood flow detected by color Doppler sonography (P < 0.05). The successful rate of air reduction was significantly higher in group A than in group B (109 of 121 versus 4 of 13). Color Doppler ultrasonography is useful to predict the reducibility of an intussuscepted intestine. The nonvisualization of blood flow by this method is not a contraindication for air reduction.

Chemical modification of surface active poly(ethylene oxide)-poly (propylene oxide) triblock copolymers

A general route has been developed to chemically modify a series of poly(ethylene oxide)-poly(propylene oxide) triblock copolymers with molecular weights from 6500 to 14600. It is initiated by the introduction of p-nitrophenyl groups; such nitrophenyl conjugated copolymers are stable in an organic milieu and in a dry state but are seen to react easily with amino-containing molecules including small peptides. Among them, introduction of 2-pyridyl disulfide groups after coupling with 2-(2-pyridyldithio)ethylamine enables the selective attachment of thiol-containing molecules. The released thiopyridone in such thiol-disulfide reactions can be used to quantify the content of 2-pyridyl disulfide groups. In addition, a new type of modified copolymers was developed for the radioisotope (125I) labeling purpose that consists of a reaction of nitrophenyl conjugated copolymers with hydrazine and a subsequent coupling with N-succinimidyl 3-(4-hydroxyphenyl)propionate (Bolton-Hunter reagent). Adsorption studies of 125I-labeled and 2-pyridyl disulfide conjugated copolymers on polystyrene particles are consistent with previous determinations of surface coverage using other technologies, in turn indicating that this new chemical modification does not alter their surfactant properties on hydrophobic solid phase. The coating of common hydrophobic surfaces with 2-pyridyl disulfide conjugated copolymers has been demonstrated as a general and robust immobilization method to generate a high-sensitivity bioactive surface with low nonspecific binding. The optimal space between immobilized ligands can also be controlled by incubating the solid phase with solutions containing mixtures with different ratios of unmodified and modified copolymers.

Diagnostic value of C-reactive protein in children with perforated appendicitis

The diagnostic value of serum C-reactive protein (CRP) levels in children with perforated appendicitis was prospectively studied in 78 consecutive patients with histologically confirmed appendicitis. The patients were divided into two groups: group A included 56 patients with perforated appendicitis and group B consisted of 22 patients with simple appendicitis. Serum CRP level and leucocyte count were assayed in all and abdominal ultrasonography was performed in 75. The mean age group A patient was significantly lower than that of group B patients (7.5 vs. 10.4 years, P < 0.001). Group A patients had a significantly higher mean serum CRP levels than group B patients (92 vs. 31 mg/l, P < 0.001), while the mean leucocyte count was comparable in the two groups. Of 75 examined patients, 73 (97%) had a pre-operative sonographic diagnosis of appendicitis.

CONCLUSION

Perforation is a common complication in children with appendicitis, especially in those of young age and with prolonged pain duration. Greatly increased serum CRP levels (> or = 50 mg/l) and abdominal ultrasonography are important diagnostic aids in such patients.

Pneumatic reduction of intussusception in children

Over the past decade, pneumatic reduction has been increasingly accepted as the treatment of choice for pediatric intussusception. However the effectiveness of air compared with the more traditional barium reduction of intussusception continues to be a source of concern and debate. From August 1993 to November 1994, pneumatic reduction was used to treat 75 episodes in 73 patients with proven intussusception at Chang Gung Memorial Hospital, Taoyuan. Two patients underwent air reduction twice because of recurrence following an initial successful reduction. The recurrence rate was 3%. Successful reduction was achieved in 65/75 (87%) episodes. None of the patients experienced any complications following the procedure. In two of the 10 patients in whom reduction failed, one was subsequently found to have a Meckel's diverticulum and the other a duplication cyst as a leading point. This prospective study indicates that air enema is a safe and effective form of treatment for intussusception in infants and children. Pneumatic reduction should be the treatment of choice in the initial management of intussusception.

Intestinal malrotation and midgut volvulus: a 15-year review

The records of 54 pediatric patients with symptomatic malrotation of the intestine seen over a 15-year period from 1978 to 1992 were reviewed. Bilious vomiting and bloody stools were the two most common clinical presentations in neonates, while bilious vomiting, recurrent abdominal pain and failure to thrive were the most common symptoms after the newborn period. Obscure symptoms, usually of appreciable duration, were common in many patients beyond infancy. Upper gastrointestinal radiologic examination is the preferred and more accurate method of diagnosing malrotation as it has greater sensitivity than barium enema study. Laparotomy showed 24 cases with midgut volvulus. The incidence of midgut volvulus in symptomatic malrotation was 42.1% in the neonatal period, and 50% beyond the neonatal period. The majority of patients were treated by Ladd's operation. Massive gangrene of the small bowel due to volvulus was noted in five neonatal cases. Three patients subsequently died of this complication. Four patients developed a bowel obstruction secondary to adhesions, which was relieved by enterolysis. This study reiterates that newborns with symptomatic malrotation require emergency laparotomy in order to prevent catastrophic massive bowel resection.

Photoaffinity labeling of antibodies for applications in homogeneous fluoroimmunoassays

A homogeneous noncompetitive immunoassay based on photoaffinity labeling techniques is described. Using this method, a fluorophore (reporter) can be specifically attached to an antibody in the vicinity of its antigen-combining sites. Upon antigen binding, changes in the fluorescence spectrum of the reporter molecule are often observed. Two fluorophores, pyrene and dansyl, were evaluated for this purpose. Also, this technology is ideal for fluorescence energy-transfer immunoassays that require labeling of the antibody with either a donor or acceptor fluorophore. In such cases, a fluorescent dye can be specifically attached near the antigen-combining site, where it can participate in high-efficiency energy transfer with its complementary fluorophore attached to the antigen.

Gastric perforation in the neonate: clinical analysis of 12 cases

Gastric perforation is a rare abdominal catastrophe which associated with high mortality in newborn infants. From June 1978 to July 1991, twelve cases of neonatal gastric perforation presented at Chang Gung Memorial Hospital. Male to female ratio was 9:3. The most common presenting signs were abdominal distension (100%), feeding intolerance (92%), respiratory distress (67%) and poor activity (58%). All cases had significant symptoms between two and five days of age. All of the abdominal plain film showed pneumoperitonium. The most common site of perforation was the great curvature of the stomach (83%). Among the 10 pathological reports available, 8 cases had ischemic change and 2 cases had hemorrhage and inflammatory cell infiltration. There was a high mortality rate of 58% in this series. Male, hyponatremia (serum sodium < 130 meq/l) and metabolic acidosis (pH < 7.3) were poor prognostic factors. This report suggests that early diagnosis and early management before clinical deterioration of the metabolic status may improve prognosis for neonatal gastric perforation patients.

Intussusception in infants and children: risk factors leading to surgical reduction

Intussusception is commonly the etiology of intestinal obstruction in infants and children. To investigate demographic data, clinicopathologic features and therapeutic prognosis of patients with intussusception, we reviewed 361 intussusceptions in 333 patients over an 11-year period. Most patients were below two years of age and there was a male preponderance of 1.6:1. There was no seasonal difference between the number of cases. The clinical triad of vomiting, abdominal colicky pain and bloody stools was manifested in only one-third of our patients. Secondary intussusception contributed to 6.6% of cases and Meckel's diverticulum was the most common pathologic cause. Positive findings were recorded in 82% of 67 patients undergoing sonographic examination. Intussusception of the ileo-colic type was most frequently encountered. Most patients (79%) were diagnosed within 48 hours and almost all cases underwent primary barium enema reduction. The success rate was 45%. Laparotomy was performed in 207 patients (57%) refractory to enema reduction or with critical illness, and intestinal resection was required in 28 (14%). Long-standing duration of illness (> 24 hours), positive clinical triad, positive pathologic lead point, and radiologic finding of bowel obstruction were identified as risk factors leading patients to surgical reduction (p < 0.001). Postoperative complications and recurrent intussusception developed in some patients, and the overall mortality was 0.6%. The clinical characteristics of intussusception in children generally remained unchanged as compared to previous reports. Early identification of patients with risk factors for surgical treatment is important to decrease the need for intestinal resection.

Anatomical findings of the vanishing testis

Inguinal exploration of 62 clinically impalpable undescended testes reveals 40 (64%) instances of absent testis. Nine (22.5%) of the 40 explorations showed complete absence of the testes along with the epididymis and vas deferens, six (15%) were associated with only vas ending blindly, and the other 25 (67.5%) were associated with blind-ending vas deferens and blood vessels: the "vanishing testis syndrome." The anatomical findings of these vanishing testes showed the presence of a vas deferens and vessels lying side by side in the inguinal canal. In Addition, two patients with bilateral vanishing testis were found to be a normal 46 xy phenotypic male. Since testicular tissue is necessary in utero to stimulate external genital development, these findings, imply that testes vanished at some point following induction of masculinization, possibly as a result of an intrauterine vascular accident or testicular torsion. Also, according to the anatomical findings of vanishing testis, it gave us the signal to terminate the exploration when we found absent testis with a blind-ending vas plus vessels on one or both side in an operation for impalpable testis.

Management of yolk sac tumor of the testis in children

Yolk sac tumor (YST) is the most common form of malignant testicular tumor in infancy and children. However, there is no general agreement on its treatment regimen due to its rare occurrence. From 1978 through 1990, 30 cases of YST of the testis were treated at Chang Gung Children's Hospital. Thirteen (43.3%) occurred in the right testis and 17 (56.7%) in the left. Age at operation ranged from six months to five years with a mean of 1.79 years. All patients received an orchidectomy as their initial treatment. Eighteen patients with stage I disease were treated by orchidectomy alone. Fourteen (77.8%) of them were free of disease, two patients who had recurrence with retroperitoneal metastasis were successfully treated with chemotherapy. The remaining two patients died of metastasis. Seven patients with stage II disease and five with stage III disease were treated with combination chemotherapy, irradiation or debulking operation following orchidectomy. Four stage II patients (57.1%) and one stage III patient (20%) showed no evidence of disease at the time of follow-up. It was concluded that for stage I disease, orchidectomy alone followed by strict monitoring of alpha- fetoprotein achieved an 89% disease-free survival rate. Retroperitoneal node dissection or routine chemotherapy added no benefit to survival. For stage II or III disease, chemotherapy or irradiation is needed to obtain a better outcome.

Repeated technetium-99m pertechnetate scanning for children with obscure gastrointestinal bleeding

From 1980 to 1992, we found false negative results from Technetium (Tc)-99m abdominal scans in seven children with massive gastrointestinal bleeding from ectopic gastric mucosae. Other examinations--including endoscopy, gastrointestinal series studies, angiography, and Tc-99m-labeled red blood cell scans to search for the source of the bleeding--were all in vain. Positive results were only obtained after repeated Tc-99m abdominal scans. Surgical specimens confirmed that ectopic gastric tissue was the source of bleeding in five patients with Meckel's diverticulum and two patients with enteric duplication.

Pyogenic liver abscess in children

Our center's experience with 15 pyogenic liver abscesses in 14 children from 1979 to 1992 showed an incidence of 20 per 100,000 pediatric hospital admissions. Eight of the 15 liver abscesses were cryptogenic in origin. The clinical features and laboratory findings were non-specific. Improved imaging techniques such as real time sonography and computed tomography made early diagnosis feasible. Klebsiella pneumoniae was the most common pathogen in this study. Drainage combined with antibiotics provides the most important treatment for this disease. Before 1986, surgery was frequently used, but now percutaneous drainage is preferred. Surgery may be reserved for those who respond poorly to percutaneous drainage and medical treatment. One of the 14 patients in this study died.

Role of parenteral nutrition in preventing malnutrition and decreasing bacterial translocation to liver in obstructive jaundice

Surgery in patients with obstructive jaundice is associated with significant infectious complications probably due to impaired immune function and malnutrition. Total parenteral nutrition (TPN) may alleviate malnutrition but may also promote bacterial translocation (BT) from the gut. To elucidate if TPN can prevent malnutrition without promotion of BT in obstructive jaundice, 40 dogs underwent laparotomy for tissue sampling and placement of a central venous line and were allocated into one of four groups: I (PO-control) received dog chow and water ad libitum; II (PO-CBDL) underwent ligation of common bile duct (CBDL) and was fed dog chow; III (TPN-control) received TPN; and IV (TPN-CBDL) underwent CBDL and received TPN. Body weight, blood samples for liver function tests and bacterial culture, and tissues from liver and mesenteric lymph nodes (MLN) for quantitative bacterial culture and for histology were obtained prior to and 2 weeks after the experiment. The incidence of BT to MLN was 40% in the PO-CBDL and TPN-CBDL animals, which was significantly different from the other two groups (0%; p < 0.05). The incidence of BT to liver was 70% (7/10) in the PO-CBDL animals, which was significantly higher than that in groups I, III, and IV (0%, 20%, 20%, respectively) (p < 0.05). The PO-CBDL animals showed a significant decrease in body weight and prealbumin compatible with malnutrition, whereas the TPN-CBDL animals showed a significant increase in alkaline phosphatase and a consistent cholestasis on histology. The data suggest that TPN can prevent jaundice-associated malnutrition and decrease BT to liver but should be administered cautiously because it may precipitate cholestasis.

Technetium-99m pertechnetate scan for ectopic gastric mucosa in children with gastrointestinal bleeding

The detectability of ectopic gastric mucosa by Technetium (Tc)-99m pertechnetate abdominal scanning was investigated by reviewing 62 such scans in 52 pediatric patients with gastrointestinal hemorrhage. The histologic diagnoses and clinical conditions were correlated to the findings of the scans. There were 21 true-positives, 35 true-negatives, one false-positive and five false-negative studies. The overall sensitivity of this scan for the detection of ectopic gastric mucosa was 81%, the specificity was 97% and the accuracy was 90%.

New observations in a child with angiofollicular lymph node hyperplasia (Castleman's disease) originated from the mesenteric root

Localized plasma cell type Castleman's disease (CD) is an unusual pathologic entity. It is frequently associated with clinical and laboratory characteristics and rarely occurs in children. Total surgical excision results in cure in all aspects. To make early diagnosis of mesenteric CD is not easy, especially for children. An 11-year-old Taiwanese boy was recently evaluated for anemia and delayed growth. His clinical findings included a syndrome of severe hypochromic microcytic anemia, neutropenia, thrombocytosis, hypoferremia, hypergammaglobulinemia, and growth failure. Radiological examinations (abdominal ultrasound, small intestinal series, and computerized tomography) identified hepatosplenomegaly, nephromegaly, and huge masses in the middle abdomen with precaval, celiac, and paraaortic lymph nodal enlargement. However, detailed physical examination failed to detect a mass. At laparotomy a double-fist-sized confluent mass was found arising from the mesenteric root. Most masses were discrete and were excised individually. The pathologic diagnosis was plasma-cell type angiofollicular lymph node hyperplasia (Castleman's disease). Seven weeks after surgery, he had an episode of acute hepatitis B. Postoperatively, he exhibited a dramatic growth spurt; the hemoglobin, red blood cell indices, serum iron, and immunoglobulins returned to normal in 2 months. Neutropenia, which has not been previously related to mesenteric CD, was an unexpected finding in our case; however, it resolved spontaneously 3 months after the surgery, suggesting its causal relationship with the tumor.

The efficacy of Kasai operation for biliary atresia: a single institutional experience

To assess the efficacy of Kasai operation for biliary atresia, 60 cases during a 14-year period (1976 to 1989) at this institution were reviewed. Thirty-four (56.7%) underwent operation within 90 days of life, 11 (18.3%) between 90 and 120 days and 15 (25.0%) beyond 120 days. Fifty-six underwent hepaticoportojejunostomy and 4 underwent hepaticoportocholecystostomy. Follow-up was 1 to 14 years (mean, 7.2 years). The postoperative follow-up of these 60 patients was categorized into five groups: group A (16 patients, 26.7%) was characterized by survival greater than 3 years and without jaundice; group B (3 patients, 5.0%) was defined as survival greater than 3 years, but with jaundice; group C (11 patients, 18.3%) was defined by survival but follow-up less than 3 years, (this group was further divided into C1 [7 patients, 11.7%] if anicteric and C2 [4 patients, 6.7%] if icteric); group D (2 patients, 3.3%) was patients who underwent liver transplantation; and group E (28 patients, 46.7%) was the group of patients who died at time of review. Group A and group C1 were interpreted as success after Kasai operation; hence, the potential success rate in this series was 38.3% (23 patients). They were long-term survivers, and most of them performed normal activities appropriate for their ages. We conclude that approximately one third of patients with biliary atresia would benefit from or be cured by this operation, which should be the first attempt in the treatment of this disease entity.

Biosensors for environmental monitoring

In this article we will outline several biosensor applications which may fill existing technology gaps in the area of environmental monitoring. The requirements for these environmental biosensors, as well as difficulties in commercialization, are also addressed.

Persistent third branchial apparatus

Neck sinuses, cysts or fistulae arising from the third branchial apparatus, have seldom been reported. Between 1979 and 1989, 16 cases were diagnosed as persistent third branchial apparatus based on a fistula open or in proximity to the pyriform sinus. There were 8 boys and 8 girls whose ages ranged from newborn to 13 years. Esophagogram was performed in 6; 4 showed a fistula tract leading to the pyriform sinus. Others were demonstrated at surgery. The main presentations were suppurative thyroiditis (5), lateral neck fistula (5), cyst (3), mass (1), abscess (1), and esophageal stricture (1). This was interpreted as a spectrum of disease that in the newborn may present as a cyst, and later in childhood as a fistula in the lower neck or recurrent suppurative thyroiditis if the fistula ends in the thyroid gland. It is imperative to search for this internal communication to the pyriform sinus to make a correct diagnosis and to avoid development of esophagocutaneous fistula postoperatively. With more awareness of this disease entity, the noted incidence should increase.

Gastrointestinal phytobezoar in children

Phytobezoars are composed of fruit or vegetable matter, including seeds, nuts, and pits, and are the most common type of bezoar associated with gastrointestinal obstruction. Eleven gastrointestinal phytobezoar in children (less than 15 years old) seen within a period of 8 years (1981-1988) were analysed. Six were boys and 5 were girls. On history, 6 patients developed symptoms after ingestion of persimmon. All cases except one occurred in late fall and winter. In 8 patients, phytobezoar was found in a single location with 5 in the ileum and 3 in the jejunum. Multiple locations were found in 3 patients. Emergency laparotomy was performed on all cases who had typical mechanical intestinal obstruction. Treatment consisted of fragmentation of bezoar with pushing toward the cecum in 9 patients, combined with gastrotomy in 3 patients, and enterotomy in 2 patients. Because the persimmon ingestion is the most common cause of bezoar formation, a careful dietary history will usually suggest the diagnosis preoperatively. All the gastrointestinal tract should be thoroughly examined intraoperatively, especially the stomach and terminal ileum, to prevent another intestinal obstruction caused by an undiscovered phytobezoar.

Spatially resolved detection of antibody-antigen reaction on solid/liquid interface using total internal reflection excited antigen fluorescence and charge-coupled device detection

Spatially-resolved detection of antibody-antigen reactions at the solid/liquid interface was investigated by total internal reflection excited fluorescence from large area flat surfaces. Anti-HSA immunoglobulin G (IgG) antibody was immobilized at four spatially distinct spots. Binding of fluorescein-labeled human serum albumin (HSA) from the solution to immobilized antibody was detected by a cooled charge-coupled device (CCD) as a charge in the fluorescence intensity. A two-dimensional representation of the fluorescence was obtained during the binding reaction time of 25 mins. The contributions from bound and free antigen to the total signal were evaluated. The influence of the scattered excitation light and the normalization of fluorescence signal with respect to the two-dimensional incident light intensity distribution are discussed.

The influence of adsorption of native and modified antibodies on their activity

Immobilization of biomolecules to solid phase materials has been widely used in many areas (e.g., purification, analytical chemistry, and catalysis). The interfacial properties of immobilized antibodies on pretreated silica and hydrogel surfaces were explored by comparing native and modified antibodies with respect to their surface activity. The antibody was modified by exposing it to a low pH solution prior to immobilization. Both physical adsorption and covalent immobilization methods were studied. It was found that the surface activity of the modified antibody is higher than that of the native antibody on two silica surfaces. The results of this study demonstrate that the adsorption properties of the antibodies play an important role in their covalent immobilization on certain types of solid supports.

Nonoperative treatment of blunt hepatic injury in children

Between January 1983 and December 1986, 35 Children with blunt hepatic injury were treated in Chang Gung Memorial Hospital. After vigorous resuscitation, 10 Patients required emergency laparotomies: 9 for massive bleeding, and 1 for associated bowel injury. Exploratory surgery was necessary 5 days after the initial resuscitation in one patient due to rebleeding. The remaining 24 patients who responded well to resuscitations were managed nonoperatively. Imaging examinations (ultrasound, radioisotope scan or computerized tomography scan) provided the diagnosis of liver trauma in all. The hospital courses in all cases were uneventful and there were no complications. In every patient follow-up imaging examinations showed complete resolution of the lesions. We conclude that nonoperative management of selected patients with blunt hepatic trauma is reasonable. With the help of serial imaging examinations, this conservative approach is safe and practical.

Management of the fetus with an abdominal wall defect: experience of 31 cases

The diagnosis of ventral abdominal wall defect can now be made prior to birth. With this diagnosis, the family can make decisions and a planned optimal management can lead to a successful outcome. There were 31 cases of ventral wall defect identified at Chang Gung Memorial Hospital (CGMH) from January 1979 through March 1988. Twenty of them were classified as gastroschisis; among them, 17 (85%) were born in outside clinics and none of them had associated anomalies. In contrast, among 11 cases of omphalocele, there was a lower frequency of transferred cases (27% vs 85%), and 4 cases had additional defects, including two multiple anomalies and two bladder exstrophies. There were no significant differences between gastroschisis and omphalocele in the mortality rate (30% vs 36%), in the incidence of intrauterine growth retardation (IUGR) (30% vs 27%) and in the Cesarean section rate (15% vs 18%). All 4 cases of prematurity (less than 36 weeks of gestational age) expired after delivery and 2 of these had body weights of less than 1500 g. Three out of 5 cases delivered by Cesarean section expired; the mortality (60%) was higher than that of vaginal delivery (28%). All 3 cases were gastroschisis, 2 of them were transferred from outside clinics and all expired due to sepsis. The diagnosis of ventral wall defect should be made prenatally, with obstetric ultrasonography, maternal serum alpha-fetoprotein screening and fetal karyotyping. Therefore, fetal transport in utero to a referral center and optimal perinatal care for those fetuses with potentially correctable lesions can be well planned.

Primary testicular tumors in children

Twenty-six primary testicular tumors in children (less than 15 years old) seen within a period of nine years (1978-1986) were analyzed. Of these, 16 (61.5%) were benign mature or immature teratomas and ten (38.5%) malignant. This is obviously different from most of the western series in which a 75-80% rate of malignancy has usually been reported. Sixteen benign testicular tumors, which were either mature or immature teratomas, showed no evidence of tumor one to nine years after high inguinal orchiectomy. Serum alpha-fetoprotein (AFP) levels were available in 14 of these patients and all of them were below 50 ng/ml. In the ten malignant tumors, eight were yolk sac tumors and two embryonal rhabdomyosarcomas. High inguinal orchiectomy only was performed for stage I disease with sequential monitoring of AFP level for two years. For stage II or III tumors, chemotherapy and/or irradiation were added in the treatment regimen. Retroperitoneal node dissections were not performed in this series. Eight out of these ten cases were alive without evidence of disease after one to seven years, one expired for an unknown cause and one was lost to follow-up. We advocate this conservative approach to childhood testicular tumors which have a better outcome than adult tumors.

Biliary sludge-cast formation following liver transplantation

The development of biliary sludge, in the absence of anastomotic obstruction in the common bile duct, has become a very rare complication following orthotopic liver transplantation since the adoption of modern techniques of biliary reconstruction and routine biliary flushing before cold preservation. We describe the successful treatment of this serious complication in an 18-year-old woman whose biliary sludge aggregated into firm casts occupying the extrahepatic and intrahepatic bile ducts causing obstruction and cholangitis necessitating operative intervention followed by interventional radiological approaches to treat the intrahepatic bile duct strictures. Postoperative choledochofiberscopy was also used to remove the retained biliary casts. The pathogenesis of biliary sludge appeared to be multifactorial, but cold ischemic damage to the bile duct wall seemed to play an important role in this case.

Differences in crystal properties and ligand affinities of an antifluorescyl Fab (4-4-20) in two solvent systems

An antigen-binding fragment (Fab) from a murine monoclonal antibody (4-4-20) with high affinity for fluorescein was cocrystallized with ligand in polyethylene glycol (PEG) and 2-methyl-2,4-pentanediol (MPD) in forms suitable for X-ray analyses. In MPD the affinity of the intact antibody for fluorescein was 300 times lower than the value (3.4 x 10(10) M-1) obtained in aqueous buffers. This decreased affinity was manifested by the partial release of bound fluorescein when MPD was added to solutions of liganded Fab during crystallization trials. In PEG, the ligand remained firmly bound to the protein. The liganded Fab crystallized in the monoclinic space group P2(1) in PEG, with a = 58.6, b = 97.2, c = 44.5 A and beta = 95.2 degrees. In MPD the space group was triclinic P1, with a = 58.3, b = 43.4, c = 42.3 A, alpha = 83.9 degrees, beta = 87.6 degrees, and gamma = 84.5 degrees. X-ray diffraction data were collected for both forms to 2.5-A resolution. Surprisingly, the triclinic form of the liganed antifluorescyl Fab had the same space group, closely similar cell dimensions, and practically the same orientation in the unit cell as an unliganded Fab (BV04-01) with activity against single-stranded DNA.

On-line sensors for coagulation proteins: concept and progress report

The assessment of blood damage and of the activation of the coagulation, complement and/or inflammatory systems by cardiovascular and extracorporeal devices is difficult at best. Immunoassay methods are now available for the measurement of many of the proteins, enzymes and peptides involved in coagulation, thrombosis, complement and inflammation. We present a long-range project and plan to develop an array of remote, on-line, semicontinuous immunosensors for selected coagulation proteins, based on fluoroimmunoassay principles. The free/bound separation step is performed optically. Excitation of fluorescence is performed via an evanescent wave produced by total internal reflection and waveguide optics. Fluorescence emission is collected only in the near field. Means to deliver fluorescently-labelled reagent and to modify the antigen-antibody binding constant are presented and discussed. The results of non-specific binding, plasma-blood fluorescence, and blood compatibility are also discussed.